Hollie Colahan Denver Zoo. JUST CULTURE: A Different Approach to Safety & Accountability

Transcription

1 Hollie Colahan Denver Zoo JUST CULTURE: A Different Approach to Safety & Accountability

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5 WHAT IS JUST CULTURE? And what it is not Just Culture is a values-supportive system of shared accountability. The employees can report mistakes, by them or others, and know that that information will feed into the safety management system. However, gross negligence, willful violations and destructive acts are not tolerated. Just Culture is NOT Blame-free culture Punitive culture Outcome based Expectation of perfection The hard parts Humans are fallible Severity of outcomes don t matter Progressive discipline isn t the answer

6 5 SKILL MODEL 1. Aligning Values and Expectations align with mission 2. Designing Better Systems anticipate errors, support good decisions 3. Making Better Behavioral Choices understand role of human behavior 4. Learning to Systematically Learn investigate, analyze, & learn from mistakes 5. Finding Justice both in the system and for the employee

7 3 DUTIES Follow procedural rules Avoid unjustifiable risk Produce an outcome

8 OUTCOME BIAS The danger of no harm, no foul We may punish when someone doesn t deserve to be punished We let risky behaviors continue unchecked Potentially overreact to singular events and underreact to risk

9 OUTCOME BIAS The danger of no harm, no foul Nothing happens Keeper leaves door open Pygmy goose escapes Tiger escapes Person injured

10 OUTCOME BIAS The danger of no harm, no foul Keeper leaves door open

11 WHY DID THIS HAPPEN? Keeper just forgot to check Keeper rushing due to tour Keeper leaves door open Keeper deliberately skips lock check

12 WHY DID THIS HAPPEN? Keeper just forgot to check Just Culture Algorithm Keeper rushing due to tour Keeper leaves door open Root Cause Keeper Analysis deliberately skips lock check

13 THE 3 BEHAVIORS The foundation of the Just Culture Algorithm Human Error At-Risk Behavior Reckless Behavior Inadvertent action: slip, lapse, mistake Manage through changes in: Processes Procedures Training Design Environment Behavioral Choices A choice: risk not recognized or believed justified Manage through: Removing incentives for atrisk behaviors Creating incentives for healthy behaviors Increasing situational awareness Conscious disregard of a substantial and unjustifiable risk Manage through: Remedial action Disciplinary action Punitive action CONSOLE COACH PUNISH

14 THE 3 BEHAVIORS Behavior Definition General Example Zoo Example Human Error an inadvertent action Run a stop sign accidentally Forgot to check animal location before entering At Risk Behavior making a risky choice we feel is safe Drive over the speed limit Rushing due to meetings later in day Reckless Behavior a knowingly unsafe decision Drive while intoxicated Tells coworker animals have been checked when they have not

15 THE 3 BEHAVIORS General Example Zoo Example Run a stop sign accidentally Forgot to check animal location before entering Drive over the speed limit Rushing due to meetings later in day Drive while intoxicated Tells coworker animals have been checked when they have not Potential Outcomes Nothing Nothing Fatal crash Animal or human fatality

16 THE 3 BEHAVIORS Console Human Error Keeper just forgot to check Coach At Risk Behavior Keeper rushing due to tour Keeper leaves door open Punish Reckless Behavior Keeper deliberately skips lock check

17 Self-reporting of near misses has increased. That has created a situation where we can investigate the situation and often make policy or procedure changes before I m excited we to work towards the have an actual incident. Just Just Culture format of finding the culture facilitates a proactive root cause of problems so that we approach to safety. Dale, are solving Curatorwhat really needs to be solved, rather than putting Band- Aids on problems that end up having to be revisited. Marcia, Assistant Curator What staff are saying Just Culture allows mistakes without stigma and encourages discussion and analysis of a problem rather than just a wrist slap. It is a much more comfortable and productive conversation for managers and employees. Rebecca, Curator People feel more valued because we can have these conservations in a more genuine and trusting atmosphere. Matt, Assistant Curator I reported an error I had made to my supervisors. Together, we came up with appropriate solutions and learning opportunities I could work on to avoid making similar mistakes in the future. I also do not feel that my job, work responsibilities, future opportunities or relationship with my supervisors were at risk. Maureen, Bird Keeper Because of Just Culture I am unafraid of admitting mistakes and feel truly supported by my team. I also feel appreciated in that I can help managers find solutions to prevent the mistake from occurring again. Holly, Animal Ambassador Keeper Decisions on consequences of actions are relatively straight forward but solutions to prevent incidents can be elusive. Just Culture provides a platform and process to identify the root cause problem to help ensure it doesn t happen again while creating an open environment to discuss safety incidents. Brian, Sr. VP for Animal Care & Conservation

18 FAQs Well, what about What about repeat offenders? What if we get sued? How would this work with a union? What will this cost? Can it be applied to things other than safety?

19 WANT TO LEARN MORE?

20 ROOT CAUSE ANALYSIS Hollie Colahan Denver Zoo

21 WHAT IS RCA? The most basic initiating event(s) of a causal chain of human errors, behavioral choices, and/or mechanical failures leading to a negative outcome. Don t jump to solutions yet! We are prone to make inferences based on our own biases and the outcome so RCA focuses on: 1. Outcomes 2. Systems 3. Future Events

22 OUTCOMES What happened? anticipated or unanticipated failure? Construct a narrative timeline and process flow Build out cause and effect relationships identify behavior choices and contributing factors Tell the story

23 SYSTEMS What normally happens? What does procedure require? How are we managing the system?

24 FUTURE EVENTS Actual event rates statistical analysis Identify frequency of at-risk behavior What layers of defense exist? Are they working?

25 WHY USE RCA? Systematic and structured process Avoids culture of individual blame Finds most effective solutions Multiple RCAs can help address organizational and system issues

26 ADVANTAGES OF RCA Reactive Learning Trial and error Event investigation Tribal knowledge Proactive Learning Data analysis ID common cause Audits and surveillance Prospective Learning Failure Modes & Effect Analysis Trajectories Risk Assessment 80% of systemic changes should come from systemic analysis, not single events

27 THE DIAGRAM

28 THE DIAGRAM Single Event Outcome Class of Outcome Causal Factor Causal Factors Causal Factors Causal Factors

29 Behavior Choice: At Risk Contributing Factors: Interpretation of Risk, Knowledge/Technical Skills Human Error: Mistake of Fact Non-Causal (Noise)

30 Behavior Choice: At Risk Contributing Factors: Interpretation of Risk, Organizational Factors Contributing Factor: Job/Task Behavior Choice: Social Benefit

31 Line thickness = causal strength

32 CAUSATION vs CORRELATION Spurious Correlations by Tyler Vigen

33 CAUSATION vs CORRELATION Spurious Correlations by Tyler Vigen

34 Risk Management Index (RMI) 1. Impact/Severity 2. Likelihood/Rate 3. Changeability

35 RMI = 216 RMI = 96 RMI = 54

36 EVENT INVESTIGATION What happened? Increasing Value What normally happens? What does procedure require? Keep asking WHY? Why did it happen? How were we managing it?

37 THANKS! Denver Zoo Phillip Bolger, Outcome Engenuity AZA Safety Committee